Lean improvement project saves $3.5 million

CEO SUMMARY: Seeking to improve turnaround time for stat lab tests, the laboratory at Sarasota Memorial Health Care System identified high rates of hemolysis as the chief reason for less than ideal TAT. Because 32% of blood draws were handled by the lab’s phlebotomy staff while 68% of blood draws were performed by nurses and emergency department technicians, the lab’s performance improvement team implemented standardized blood draws facility-wide. Hemolyzed specimens fell below 2% hospital-wide and $3.5 million in savings were realized.

HEMOLYZED BLOOD SPECIMENS are the bane of every clinical laboratory. Each hemolyzed specimen can delay appropriate patient care and is an unnecessary increase to the cost of laboratory testing.

It is a universal problem, with many root causes that often fall outside the clinical lab’s ability to address. Thus, it is notable when any laboratory tackles the problem of hemolyzed specimens and can lower the rate by a dramatic amount and sustain those gains. Such was the case for the laboratory at Sarasota Memorial Health Care System, in Sarasota, Florida.

Following a series of Lean and process improvement projects launched in 2009, the rate of hemolyzed specimens—as high as 11% in one department—was driven down to less than 1% in most departments in the hospital.

The direct benefits to patient care are obvious. But equally significant is that this quality improvement initiative has saved the hospital $3.5 million since its implementation.

As is true at most other hospitals, the problem of hemolyzed specimens was particularly acute for blood specimens collected in the Emergency Care Center (ECC). “Further, the hemolysis rate across the entire hospital was much higher than the hemolysis rate for the lab’s phlebotomy staff,” explained Laboratory Director Charlene H. Harris, FACHE, MT(ASCP).

“Hemolyzed specimens not only delay patient care because of the need to redraw the patient, but hemolyzed specimens are also a major source of patient dissatisfaction,” she said. “Patients invariably are unhappy about the need to be stuck with a needle a second time. It is also true that these same patients often recognize that someone on the hospital staff did not properly collect or handle their original blood specimen.”

At 806 beds, Sarasota Memorial Hospital is the second largest acute care public health system and hospital in Florida. It has specialized expertise in heart, vascular, cancer, and neuroscience services. “Our clinical lab runs about 2 million billable tests per year,” noted Harris. “Our lab’s phlebotomists collect only 32% of all specimens in the facility. Nurses and medical technicians collect the remaining 68%.

“One thing that distinguishes Sarasota Memorial Health System is its culture of quality,” continued Harris. “HealthGrades has named us as one of the top 50 best hospitals in the United States for five consecutive years. We are one of only five hospitals in the United States to earn this recognition.”

During a presentation at the Lab Quality Confab in San Antonio last November, Harris pointed out that this “culture of quality” across the entire health system played a role in the lab’s effort to reduce hemolysis rates. “There is support at the highest levels for these types of continuous quality improvement efforts,” emphasized Harris.

“For example, one favorite expression of our CEO, Gwen MacKenzie, is ‘The relentless pursuit of quality,’” noted Harris. “That message is understood by everyone working within our health system. It helped our lab gain the active support of nurses, physicians, and other staff for our efforts to reduce the rate of hemolyzed specimens across the entire hospital.

Reducing Lab Test TAT

“It was 2009 when we started our improvement project with the goal of reducing lab test turnaround time (TAT),” stated Dana J. Rickard, the lab’s Pre-Analytical Manager. “Of course, hemolyzed specimens are one source of delayed TAT. To help us, we turned to Charlotte Damato, who is the Lean/Six Sigma Quality Coach at our hospital.”

“The lab team analyzed all the processes involved in testing,” noted Damato. “Five significant processes had the greatest impact on turnaround times for stat testing. Some of these processes are unique to our facility, but most of these will be familiar to anyone working in a hospital laboratory.

“The first of these five issues centered upon how the pneumatic tube system was involved in causing TAT delays,” she recalled. “Nurses on the floors would send specimens through the tube system— including stool and urine samples. Sometimes the collection cups were not sealed properly or they were not placed in the correct transport container.

Improperly-Sealed Samples

“When sent through the pneumatic tube system, improperly-sealed samples would sometimes leak outside the carrier,” explained Damato. “At that point, the staff would immediately shut down the entire pneumatic tube system for cleaning and sanitizing. This can take an hour or more. That happened at least once a week and often more than that.

“A second source of delay was how lab specimens collected in the Emergency Care Center (ECC) were handled,” she said. “All stat tests from the ECC dropped into a lab pneumatic tube station with lab specimens from other units in the hospital. That made it impossible to tell stat lab specimens from any other specimens in the bin. This source of delay was fixed by having ECC staff use only red canisters for stat specimens.

“The third source of turnaround time delays for stat lab specimens involved the ECC nurses,” noted Damato. “They often drew blood before they got an order to do the draw. By sending specimens to the lab without an order, these stat tests would sit in a holding pen awaiting an order.

“Our root cause analysis showed that, whenever the ECC drew the blood before getting an order, it took an average of 34 minutes longer to get a lab result than if the lab had taken the order and performed the blood draw,” she observed.

“Four was a common problem in many hospital labs: frequent phone calls to the preanalytical department,” commented Damato. “There could be 30 calls an hour and some were for ridiculous requests. Someone would call and say, ‘I need a red tube’ or ‘I need a baggy.’ We revised the process for answering these calls so that work in the preanalytical department was not continuously interrupted.

“Five was high rates of hemolysis, and this factor had a big impact on TAT,” stated Damato. “At the time, we noticed, of all groups and departments involved in collecting lab specimens, our phlebotomists had the lowest hemolysis rates.

“Of these five sources of delays in lab test TAT, we believed driving down the number of hemolyzed specimens had the potential to generate the biggest improvement,” noted Damato. “The hospital-wide hemolysis rate was over 2%, but the rate for specimens collected by our phlebotomy staff was 2% or less. We believed that we could get the entire facility down to this 2% rate.

“Keep in mind that, back in 2009 the rate of hemolyzed specimens was about 10% for the ECC,” she added. “We established the 2% rate as the stretch goal for this improvement project.”

The Source of the Problem

Damato noted that the hemolysis rate data from across the entire hospital showed which units had the greatest potential for improvement. “We could see that the highest hemolysis rates were from the ECC,” she said. “The ECC is divided into pods and even the best ECC pod was at 5.8%; the worst pod was 11%. This told us where we had to start implementing solutions.”

At about this time, the lab tapped a new vendor for help in its quality improvement project. “We are always looking to find the best value and so I asked this vendor— Becton Dickenson (BD)—about our hemolysis rates,” recalled Rickard. “BD offered to help with the staff education.

“Our strategy was to have BD—as an outside expert in this field—send its trainers to all areas where nurses draw blood on the floor and where multi-skilled techs draw blood in the ECC,” she said.

“These trainers used a non-confrontational approach in each department,” recalled Rickard. “They didn’t observe over anyone’s shoulder. Instead, they handed out the collection supplies and asked how they were used.

“These outside trainers found that there were different blood collection procedures and supplies used throughout the hospital,” she said. “In fact, they identified 11 different procedures for drawing blood! It wasn’t pretty. The BD trainers even found that the phlebotomists did not consistently follow all ‘Best Practices.’ At that point, they made a number of recommendations to us.

“Our next step was to have BD provide the necessary education throughout the hospital,” Rickard said. “That meant explaining the proper procedures, making sure there were standardized collection supplies available on all the nursing floors, and explaining how and why hemolysis occurs when the incorrect collection process is used. We had not done a good job explaining the reason ‘Why’ previously.

IT WAS AN AMBITIOUS GOAL TO REDUCE the rate of hemolyzed specimens across many different units of 806-bed Sarasota Memorial Hospital. The Lean project was originated by the clinical laboratory and the improvement plan focused on the Emergency Care Center (ECC).

An assessment of current state was conducted. After several of the implementation strategies were presented to the nursing units, all 15 units also reduced their hemolysis rates. The table below shows the before and after performance of each unit that participated in this Lean project. The goal was for each unit to reduce the hemolyzed specimen rate to under 2%.

When Hemolysis Occurs

“In fact, the nursing staff and the ECC MSTs thought that the lab caused hemolysis,” she said. “They didn’t realize that most hemolysis occurs at the point of collection. That was a major insight for them.

“Having BD do the best practice education helped hospital staff more readily accept this information,” added Rickard. “After that, the lab staff was seen as experts in blood draw, which was much improved from how we were viewed previously and now our interactions are much more collaborative.”

“Once we had the data, we met with the nursing coordinator and the education coordinator to identify the minimal procedures we have the staff follow,” Damato added. “The procedures included letting the alcohol dry, keeping the tourniquet time to less than a minute, and gently inverting the tube.

Blood Collection Tip Sheet

“We developed a tip sheet that we put on the back of the procedure and put the procedures all over the hospital—wherever blood collection supplies were kept,” she said.

“By 2010, we were measuring signifycant improvements in the rate of hemolyzed specimens,” continued Rickard. “But in the ECC, that rate of hemolyzed specimens continued to be above 2%.

“Among the different ECC pods, these rates were at 3.1%, 3%, and 2.3%,” she added. “It was challenging to drive those rates below 3%. At that point, an ECC Director suggested we have phlebotomists do the draws in the ECC to see if hemolysis rates can go down to 2% in a fast-paced environment like the ECC.

“We agreed. For a six-week period beginning in October 2010, two phlebotomists were assigned to the ECC for 12 hours a day, seven days a week,” she said. “With phlebotomists doing the collections, hemolysis rates went down to under 2% in the two pods. Blood culture contamination rates also declined by a significant amount.

“Hospital-wide, we reduced hemolysis by 67%,” she said. “Even the phlebotomists—who had the lowest rates at the start of this improvement program— reduced their hemolysis rates by over 70%!”

During the course of the improvement project, workflow changes within the laboratory itself contributed to a higher rate of hemolysis. “In the middle of this project, we saw an upward tick in the hemolysis rate,” recalled Rickard. “The lab had installed new analyzers.

“The change was that hemolysis was no longer being detected visually,” she continued. “These new lab instruments were detecting hemolysis spectrophotometrically and the equipment was more precise than the lab techs at detecting hemolysis.”

It has been almost two full years since this improvement project was completed. Sarasota Memorial Health System has sustained its performance in lowering the rate of hemolyzed specimens.

“A new procedure was implemented as part of this project,” stated Damato. “Each month, every department gets a report of hemolyzed specimens. It allows them to monitor the performance of their team.

“We are proud of these improved outcomes,” she noted. “As of last year, the ECC was 0.88%, housewide was 0.86%, and phlebotomy was 0.13%. These rates are significantly below the national average for hemolyzed specimens. Unit-specific hemolysis rates are reported monthly.”

The Cost-Savings Model

Every performance improvement project needs to estimate cost savings. “Our lab’s improvement team started by looking at what was saved in supplies and the reduced turnaround time for stat testing,” stated Damato. “The value of having outside experts from BD help us is that they showed us other criteria to measure that represent important sources of savings and improved patient outcomes.

“BD gathered data on length of stay and the number of patients in the ECC who left without being seen,” she explained. “BD put that data in a cost-savings model that included: 1) the costs of supplies not used; 2) the time not wasted for redraws; and, 3) the reduced turnaround time.

Exposing Common Myths about Source of Hemolyzed Specimens Played a Key Role

EVERY HOSPITAL LABORATORY WAGES AN ONGOING BATTLE to help keep the rate of hemolyzed specimens at the lowest possible level. As part of a Lean project to achieve and sustain substantial reductions in the number of hemolyzed specimens, Sarasota Memorial Hospital’s laboratory team decided to explode the three big myths associated with hemolyzed specimens. It was called the “Myth Busting Education Program” and was conducted prior to implementation of best practices to reduce the rates of hemolyzed specimens in different units.

Myth One: We are saving the patient a venipuncture if we draw from the IV start.

Myth Buster: If hemolysis occurs, the patient has a longer wait and the patient must have a venipuncture anyway.

Myth Two: Collecting blood at the time of IV start, before the test order is in the computer, saves time.

Myth Buster: Actual data showed that collecting blood before a test order is placed increased turnaround time for blood test results by 30 minutes, plus more blood was collected than needed.

Myth Three: Nurses are as good or more skilled than phlebotomists for blood collection.

Myth Buster: Hemolysis rates of specimens collected by phlebotomists are consistently below 1% in all settings. Phlebotomists are trained for all types of blood collection, even the most difficult ones. After phlebotomists worked in the ECC, nurses respected their ability and called on them to help with difficult sticks.

“Taken together, all of these sources represent a total savings of $3.5 million,” added Damato. “This resulted from significantly reducing rates of hemolyzed specimens and sustaining these reductions across the entire hospital since the inception of this performance improvement project.”

Damato shared three key lessons that can be used by other hospital laboratories. “First and foremost, quality improvement across the entire institution requires time,” she observed. “Processes must be changed, along with the culture of the institution. Taking time to engage and develop collaboration ensures downstream success.

“Second, don’t be afraid to tap your lab vendors on the shoulder and ask for their help,” continued Damato. “They have expertise and resources that can help your improvement project. Further, they have the experience of working with hundreds and thousands of their lab customers. So they bring deep knowledge and hands-on experience to the project.

“Three, celebrate success and keep the numbers visible throughout the hospital,” she concluded. “People like to be part of a winning effort. Posting on-going performance reports helps them stay focused to continue doing the steps necessary to sustain that level of achievement and improve further.”

Probably the best outcome of all is that patients are happier. Not only do they avoid unnecessary needle sticks and the collection of a second specimen of blood, but their lab test results are reported more quickly, and that contributes to faster diagnosis and treatment.